Insights^

On February 3, 2026, the House Energy and Commerce Oversight Subcommittee held a hearing to examine fraud in the Medicare and Medicaid systems. There was strong bipartisan agreement that fraudulent actions need to be addressed, however, Republicans and Democrats shared different views on best practices for preventing and investigating potentially fraudulent activity.

OPENING STATEMENTS

• Subcommittee Chairman John Joyce (R-PA-13)

• Subcommittee Ranking Member Yvette Clarke (D-NY-9)

• Full Committee Chairman Brett Guthrie (R-KY-2)

• Full Committee Ranking Member Frank Pallone (D-NJ-6)

WITNESS TESTIMONY

• Jessica Gay, CPC, AHFI, CFE, Vice President and Co-Founder, Integrity Advantage – Testimony

• Kaye Lynn Wootton, JD, President, National Association of State Medicaid Fraud Control Units – Testimony

• Stephan W. Nuckolls, Chief Executive Officer, Coastal Carolina Health Care, PA and Treasurer and former Board Chair, National Association of Accountable Care Organizations (NAACOs) – Testimony

• Jessica Tillipman, JD, Government Contracts Advisory Council Distinguished Professorial Lecturer in Government Contracts Law, Practice and Policy, George Washington University Law School – Testimony

MEMBER DISCUSSION

How Fraud Occurs

Rep. Russ Fulcher (R-ID-1) questioned if some states are targeted due to lower barriers of entry for fraudulent programs. Ms. Gay shared that in her experience, there are common states where fraud begins but will often spread to other states. Ms. Wootton shared that fraud schemes are evolving by crossing state lines, which used to be more uncommon, and the increased use of electronic health records make it easier to forge documentation.

Rep. Dianna DeGette (D-CO-1) asked for clarity on whether fraud is more commonly carried out by providers or beneficiaries. Ms. Wootton responded that far more providers commit fraud.

Rep. Paul Tonko (D-NY-20) asked if there is a difference between improper payments and fraud. Ms. Tillipman shared that often, improper payments are not fraud and that 77% are administrative errors. Rep. Tonko questioned if there were harms in labeling all improper payments as fraud to which Ms. Tillipman responded that it can make fraud investigations more difficult as well as diminish taxpayer faith in government.

Rep. Dan Crenshaw (R-TX-12) was curious if there were specific reasons why Medicare and Medicaid programs seem to be much more vulnerable to fraud than private programs. Ms. Gay shared that the national scope of Medicare and Medicaid make it much more appealing to target and the lack of an Explanation of Benefits provided to beneficiaries makes it easier to create fraudulent bills.

Rep. Diana Harshbarger (R-TN-1) questioned if expanded telehealth services could aid in fraud. Ms. Gay responded that reduced barriers to care and the ability for providers to cross state lines make it easier for fraudulent activity.

Fraud Investigations

Rep. Fulcher asked Ms. Wootton if fraud investigations were different for foreign actors than citizens, which Ms. Wootton denied.

Rep. Gary Palmer (R-AL-6) questioned if state auditors should have greater access to data to best investigate fraud allegations. Ms. Wootton shared that investigators need to see as much data as possible to produce a complete investigation, however, she is often limited to Medicare and Medicaid data and would like to find a way to also be able to access 3rd party and private payer data.

Rep. Troy Balderson (R-OH-12) wondered how long the average investigation lasts, which Ms. Gay shared was about a year, due to needing time to collect data to build the case as well as give an appeal time frame. The investigation is then shared with law enforcement. Rep. Balderson asked Ms. Wootton if investigators can recover fraudulent payments. Ms. Wootton responded that the payments are often either already spent or hard to track, which makes them difficult to recover. Rep. Balderson was interested in the impact of AI on fraud schemes and investigations, so Ms. Wootton shared that fraud control units are receiving training on how to identify AI modified data.

Rep. Kevin Mullin (D-CA-15) shared concerns about collaborating across government sectors and asked if investigations had better outcomes when local, state, and federal agencies were all involved. Ms. Wootton shared that, in her experience, states do not have the ability to cross borders which makes federal collaboration vital. Rep. Mullin asked if completely freezing government funding to suspected fraudulent programs is helpful to the investigation. Ms. Tellipman answered that blanket freezing does not improve the investigation and will harm individuals receiving proper services.

Impact of Fraud

Rep. Rick Allen (R-GA-12) requested that Mr. Nuckoll expand on the impact of fraud on the ability for Accountable Care Organizations (ACOs) to provide care to seniors. Mr. Nuckolls explained that ACOs share costs with the federal government and when spending for the plan is greater than the budget, the ACO must repay Medicare the difference. With increased fraud claims, ACOs often need to repay Medicare more which will force ACOs to leave the care space if they cannot afford the increased costs. Rep. Allen followed up by asking what the impact will be for beneficiaries, which Ms. Wootton responded that many will not be able to receive services without jumping through hoops.

Rep. Crenshaw asked Ms. Gay to elaborate on the impact to beneficiaries when fraud is not controlled. Ms. Gay shared that in her experience, it increases the chance that beneficiaries do not receive the care that they need, either through complete denial or subpar treatment. Another experience that Ms. Gay has seen is documentation of conditions in a beneficiaries’ chart without a proper diagnosis, which can impact access to care further down the road.

Ranking Member Pallone questioned if there was risk to programs and program participants when fraud is overstated or action taken preemptively. Ms. Tillipman explained that if fraud is overstated, it can make it more difficult to direct limited resources to the proper investigations which can make it more difficult to address true fraudulent activity.

Rep. Buddy Carter (R-GA-1) asked if artificially reducing payment rates for common fraudulent services, such as skin substitutes, would impact access to care for patients. Mr. Nuckolls responded that yes, patients will not receive skin substitutes as providers will not be able to afford the cost without proper reimbursement.

Preventing Fraud

Rep. Kim Schrier (D-WA-8) asked if proper enforcement is a strong deterrent for potential fraud schemes, with which Ms. Tillipman agreed.

Reps. Schrier and Lizzie Fletcher (D-TX-7) wanted recommendations for fraud prevention. Ms. Tillipman suggested the Committee look to the currently unimplemented recommendations from the Government Accountability Office and the Inspector General.

Rep. DeGette shared her concerns that the Department of Health and Human Services (HHS) has reduced their number of Inspector Generals by 18, or 10%. Rep. DeGette asked Ms. Wootton if this would have an impact on fraud prevention and investigation. Ms. Wootton responded that HHS is most effective when completely staffed.

On January 29, 2026, the Medicaid and CHIP Payment and Access Commission (MACPAC) met for its January meeting. The Commissioners heard a presentation from MACPAC staff on considerations for implementing community engagement requirements passed in the 2025 reconciliation legislation, before discussing the draft principles and policy recommendation to be included in their June report to Congress. The Commissioners were supportive of the draft principles but had suggestions for improving the draft policy recommendation.

The session began with MACPAC staff providing an overview of the community engagement requirements. MACPAC staff presented 4 draft principles from research with stakeholders: The Centers for Medicare and Medicaid Services (CMS) should provide timely federal guidance and technical assistance to states, CMS and states should ensure that eligible individuals can gain and maintain coverage, CMS and states should prioritize efficiency when procuring, updating, and operating state information technology (IT) systems, and CMS and states should use timely monitoring and evaluation data to inform policy and operations. MACPAC staff then presented a policy recommendation on monitoring and evaluating community engagement requirements in Medicaid, which reads “The Secretary of the U.S. Department of Health and Human Services (HHS) should direct the CMS to develop a transparent plan for monitoring and evaluating community engagement requirements in Medicaid that provides insight into how such policies affect eligibility and enrollment, health status, employment, and the attainment of other identified policy goals. CMS should identify new metrics for state reporting, as needed, and build upon existing data collection activities to minimize administrative burden. Additionally, CMS should ensure the timely publication of monitoring and evaluation results to inform policy and operational decision making.”

All Commissioners agreed with the presented principles, feeling that they properly addressed implementation concerns. For the first principle, one Commissioner suggested adding an implementation readiness checklist developed by CMS to assist states in their internal evaluation of readiness by the end of 2026.

Commissioners raised more concerns about the policy recommendation. A couple of Commissioners felt MACPAC should recommend statutory changes for monitoring and evaluation instead of the proposed recommendation for HHS to direct CMS. Multiple Commissioners expressed support for including language about assessing the costs and benefits of implementation on the Medicaid population. Some possible measures raised include time spent on requirement appeals, time spent uninsured, and the rate of increased work experiences. In response, a few Commissioners pointed out that while these measures are helpful data points, collection may be difficult as CMS does not currently have a way to measure them. Some Commissioners requested that more specific language than “health status” be included in the policy recommendation, feeling that it was too broad a category. MACPAC staff requested that Commissioners share their thoughts on what specifics to include.

A few other suggestions were raised by Commissioners. One Commissioner wanted more language encouraging automated processes to help beneficiaries demonstrate community engagement and to evaluate alternatives to wet signature requirements on paperwork, due to concerns that they create an undue burden. Another Commissioner suggested that CMS solicit a request for proposals (RFP) for research and evaluation of the impacts of community engagement requirements. Lastly, a Commissioner indicated a need to better understand the beneficiary population that will still receive benefits, citing concerns that they will be higher risk and have greater health needs, which might result in the policy not producing the expected cost savings.

On January 22, 2026, the House Energy and Commerce Health Subcommittee and the House Ways and Means Committee held hearings to investigate commercial health insurance costs. There was bipartisan agreement in both hearings that U.S. health care spending is high and that the rate of return for the American people is far short than what it should be. The insurance companies CEOs tended to agree but also cited growing health care demand and the rising cost of health care services as reasons for increased health insurance costs. There were also concerns raised by members on both sides of the aisle about consolidation and integration as well as concerns about improper denials of care. However, members on both Committees divided along familiar lines about the impact of the Affordable Care Act (ACA) and the enhanced advance premium tax credits (APTCs) on health care affordability. The leadership of both Committees have said today’s hearings are just the first step into looking into concerns about rising health care costs.

OPENING STATEMENTS

• House Energy and Commerce Health Subcommittee Chairman Morgan Griffith (R-VA-09)
• House Energy and Commerce Health Subcommittee Ranking Member Diana DeGette (D-CO-01)
• House Energy and Commerce Chairman Brett Guthrie (R-KY-02)
• House Energy and Commerce Ranking Member Frank Pallone (D-NJ-06)
• House Ways and Means Committee Chairman Jason Smith (R-MO-8)
• House Ways and Means Committee Ranking Member Richard Neal (D-MA-1)

WITNESS TESTIMONY

• Mr. Stephen Hemsley, CEO, UnitedHealth Group – Testimony
• Mr. David Joyner, Chairman and CEO, CVS Health – Testimony
• Ms. Gail Boudreaux, President and CEO, Elevance Health – Testimony
• Mr. David Cordani, President, CEO, and Chairman of the Board, The Cigna Group – Testimony
• Mr. Paul Markovich, President and CEO, Ascendiun – Testimony
• Ms. Ellen Allen, Executive Director, West Virginians for Affordable Health Care (Energy and Commerce Health Subcommittee Witness) – Testimony
• Ms. ReShonda Young, Resident of Waterloo, IA, and Owner, TnK Health and Nutrition (Ways and Means Committee Witness) – Testimony

MEMBER DISCUSSION

ACA and Enhanced APTCs

Republicans argued that the ACA did not make health care more affordable and that APTCs papered over the rising cost of health care and have driven fraud and improper enrollment in the marketplace. Democrats countered that the ACA, while not perfect, has helped millions get health insurance coverage and accused Republicans of using the hearing to distract from the fact that they allowed the enhanced APTCs to expire. Regarding fraud, Rep. Lloyd Doggett (D-TX-35) criticized Republicans who have cited a Government Accountability Office (GAO) report on the risk of fraud associated with the enhanced APTCs, saying that fraud was committed by insurance brokers, not enrollees. Rep. Adrian Smith (R-NE-03) later noted that both fraud and improper enrollment associated with enhanced APTCs need to be dealt with.

Vertical Integration and Consolidation

One of the most common topics brought up by the committee members was consolidation and vertical integration. Rep. Diana Harshbarger (R-TN-01) raised concerns about companies steering patients to their own clinics to increase profits, but Mr. Hemsley and Mr. Joyner both shared that their companies see integration as a way to provide better value and consumer experience while addressing the challenges of health care fragmentation. Rep. John Joyce (R-PA-13) asked the panelists if highly consolidated markets make it harder to contract competitive rates with insurance companies, which all panelists agreed. Rep. Lori Trahan (D-MA-03) questioned why consumers should believe that consolidation lowers costs, to which none of the panelists had an answer. Rep. Trahan continued, sharing that research has shown that consolidation raises prices.

During the House Ways and Means hearing, Chairman Jason Smith (R-MO-8) kicked off his questioning by asking insurance company CEOs to raise their hands in response to questions about employing providers, owning pharmacies, and owning pharmacy benefit managers (PBMs). When many of them raised their hands, Chairman Smith noted his concerns about how integration and consolidation have not led to reduced premiums. Other members of the Committee, on both sides of the aisle expressed similar concerns.

HSAs

Energy and Commerce Committee Ranking Member Pallone (D-NJ-6) asked Ms. Allen if a health savings account (HSAs) containing a few thousand dollars would be more helpful than an extension of APTCs. Ms. Allen replied that a few thousand dollars would only amount to 1 month of premiums, making it much less helpful for affordability. Rep. Lizzie Fletcher (D-TX-07) asked the panel if HSAs could be used to pay premiums, to which all panelists responded no. Rep. Kat Cammack (R-FL-03) suggested passing legislation to allow premiums to be paid with HSA funds. Rep. Cliff Bentz (R-OR-02) highlighted that HSAs would allow patients to earn interest on the money instead of health insurance companies earning interest on premium subsidies.

Pharmaceutical Industry and PBMs

Multiple members raised concerns about the pharmaceutical industry and the need for PBM reform. Rep. Erin Houchin (R-IN-09) wanted the panel to clarify how PBMs and group purchasing organizations (GPOs) can be so profitable if they claim to pass savings onto patients, but no panelist answered. Rep. Mariannette Miller-Meeks (R-IA-01) was interested in why many GPOs are headquartered internationally and suggested the committee look at future legislation to address it. Rep. Jake Auchincloss (D-MA-04) questioned the reasoning for UnitedHealth Group to have both a PBM and a GPO but Mr. Hemsley did not provide a clear answer. Rep. Auchincloss requested that the committee investigate how PBMs and GPOs function.

Prior Authorization and Claim Denial

Many committee members questioned the high rates of claim denials for UnitedHealth Group. Rep. Debbie Dingell (D-MI-06) and Rep. Nanette Diaz Barragan (D-CA-44) requested that Mr. Hemsley explain why analysis indicates that UnitedHealth Group denies 33% of claims, which is the highest rate in the United States. Mr. Hemsley responded that internal reports indicated only 2% of claims are denied. Rep. Kim Schrier (D-WA-08) asked why Medicare Advantage plans will often deny or delay paying claims for services already rendered that have been deemed necessary by medical professionals. Mr. Hemsley stated that patients should receive care that medical professionals feel is appropriate. Rep. Robin Kelly (D-IL-02) was interested in knowing if UnitedHealth Group uses AI to deny claims, but Mr. Hemsley assured the members that AI is only used for administrative purposes such as gathering documents.

During the Ways and Means Committee hearing, members on both sides of the aisle also brought up concerns about improper prior authorization. Members such as Reps. Mike Thompson (D-CA-4) and Greg Murphy (R-NC) expressed frustrations about patients being improperly denied care. Rep. Murphy even went so far as to say that if he had his way he would make all of them nonprofit because in his view, insurance companies put made profit over patients. Rep. Thompson asked a similar question about the use of AI for prior authorization as Rep. Robin Kelly did during the Energy and Commerce hearing and got similar answers. He said something needed to be done, because all he hears from doctors in is district is about improper denials. Rep. Mike Kelly (R-PA-16) mentioned his Improving Seniors’ Timely Access to Care Act. Rep. Linda Sánchez (D-CA-38) said she believes insurers should be penalized for denials if they are overturned. Rep. Jimmy Panetta (D-CA-19) asked if the insurance CEOs would support legislation such as his Requiring Enhanced and Accurate Lists (REAL) Health Providers Act, which would require insurance companies to update their network directories annually. The CEOs all said they are committed to working on the issue of network accuracy. Approaching things from a different angle, Rep. Terri Sewell (D-AL-7) expressed concerns about the impact of claims denials on rural providers.

Other Medicare Advantage Concerns

During the Ways and Means Committee hearing, members on both sides of the aisle also brought up other concerns related to Medicare Advantage beyond just improper denials. Rep. Doggett brought up his concerns that insurance companies are getting paid for providing care to Veterans on Medicare Advantage plans when the Department of Veterans Affairs (VA) already pays for that care. Rep. Doggett mentioned legislation to address that, and Rep. Thompson also expressed support for that bill. Rep. David Schweikert (R-AZ-1) expressed concerns about the Medicare Payment Advisory Committee (MedPAC) findings that Medicare Advantage costs more than traditional Medicare, and he asked the CEOs about how to get Medicare Advantage back to being a system that would incentivize better outcomes and lower costs. Mr. Hemsley took issue with MedPAC’s estimates but said he would be happy to work to improve Medicare Advantage.

Health Affordability Improvements

When asked by Rep. John James (R-MI-10) if they felt health care is affordable, none of the panelists agreed. Rep. Nick Langworthy (R-NY-23) asked what steps each company was taking to lower premiums for their members. Mr. Hemsley shared that UnitedHealth Group is focused on managing costs, providing better care coordination, and using a value-based care reimbursement model. Mr. Joyner said that CVS remains committed to improving the health status of population they serve, which they do through prevention, access to low-cost therapies and reimbursing on an outcomes-based model. Ms. Bourdeaux shared that Elevance Health is improving their prior authorization process to reduce complexity, is committed to reducing fraud, waste, and abuse, and is reimbursing for value and outcomes.

Other Topics

• Rep. Vern Buchanan (R-FL-16) expressed his support for preventive health care (including the need to ensure access to healthy food).

• Rep. Doggett asked the Committee’s leadership to ask Centers for Medicare and Medicaid Services (CMS) Administrator Dr. Oz to testify about the Trump administration’s decision to reinstate certain insurance brokers who had committed fraudulent activity.

• Several members, on both sides of the aisle, expressed concerns that insurance company stocks and executive compensation have risen, even though access to affordable care and health care outcomes have not improved.

• Rep. Murphy expressed frustration that in his view, insurers are fraudulently keeping money that should be due to providers under the No Surprises Act.

• Reps. Judy Chu (D-CA-32) and Brad Schneider (D-IL-10) expressed concerns about the impact of decisions by Health and Human Services (HHS) about vaccine recommendations for children on vaccine access. All the insurance company CEOs said they were not planning on making changes to their coverage policies for vaccines.

• Several members of Congress expressed concerns about the impact of health insurance costs on rural communities. In response to a question from Rep. Michelle Fischbach (R-MN-7), Mr. Hemsley said challenges in access to care in rural communities lead to higher insurance costs.